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Preventing Pressure Ulcers in the Veterans Health Administration Using a Virtual Breakthrough Series Collaborative
Lisa Zubkoff1, Julia Neily, Beth King
1VA National Center for Patient Safety, White River Junction, Vermont (Drs Zubkoff, Young-Xu, and Mills and Mss Neily, and Boar); Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (Dr Zubkoff); National Center for Patient Safety, Ann Arbor, Michigan (Ms King); and Office of Nursing Services, VA Central Office, Washington, DC (Ms Morgan).
Abstract:
The Veterans Health Administration implemented a Virtual Breakthrough Series to prevent pressure ulcers. The pressure ulcer rate decreased from 1.2 to 0.9 per 1000 bed days of care (P = .017). The most common interventions were education (N = 26; 68%), improved documentation (N = 23; 61%), and the use of equipment and supplies (N = 21; 55%). In summary, this project helped improve pressure ulcer rates in the Veterans Health Administration and presents a promising model for implementing a virtual model for improvement.
